Provider Demographics
NPI:1083675870
Name:STERNBURG, JON KOGOD (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:KOGOD
Last Name:STERNBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2121
Mailing Address - Country:US
Mailing Address - Phone:570-251-6500
Mailing Address - Fax:570-253-8174
Practice Address - Street 1:1839 FAIR AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2121
Practice Address - Country:US
Practice Address - Phone:570-251-6500
Practice Address - Fax:570-253-8174
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025493E207Q00000X
NY1471641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00679718Medicaid
29942OtherGEISINGER HEALH PLAN ID
NY69A131OtherBLUE SHIELD ID NUMBER
PA000835304Medicaid
002313OtherFIRST PRIORITY HEALTH ID
PAST415829OtherBLUE SHIELD ID NUMBER
NY69A131Medicare ID - Type Unspecified
NY00679718Medicaid
NY080169186Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID
29942OtherGEISINGER HEALH PLAN ID
NY69A131OtherBLUE SHIELD ID NUMBER